1136 / Implementing and increasing compliance with hand hygiene procedures

ITALY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Education in Patient Safety
Implementation of Patient Safety initiatives / Activities There is no specified text here
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
To Implement and increase the members' participation to hand hygiene procedures and policies within the San Matteo Hospital Foundation
Description of the Patient Safety Practice
 
Since 2009 the San Matteo Hospital Foundation is one of the promoters and a target hospital for the "hand hygiene" project supported by the World Health Organization (WHO) . The S.Matteo has appointed a Committee for Hospital Infections (CHI ) to manage the healthcare correlated infections (HCI) and the hospital program to implement and increase the participation with hand hygiene procedures. The methods adopted were compliant with WHO's guidelines, and in particular, the implemented actions were: 1 Increase in the number of dispensers with alcohol-based solutions , in the locations where the healthcare service is delivered , and in particular points easily accessible to all those who have access to care services . 2 Activation of a continuous training program for health professionals, through specific training events, videos, posters and demonstrations. 3 Complementing the training of nursing students with best practices on hygiene 4 Monitor the adherence to hand hygiene through periodic visual inspections, monitoring of soap and dispenser use, and a continuous feedback to the clinical staff. 5 Implementation of a dissemination policy which include new posters , brochures and information leaflets for patients and visitors. These actions have resulted in an improvement in the average rate of hand hygiene compliance from 55% in 2010 to 73% in the year 2013.
The methods used for evaluating results were the continuous monitoring of compliance to the practice through periodic assessment of the consumption of soap and alcohol gel and through the use of framework.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
There is no specified text here
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
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Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Not relevant
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Physicians
Nurses
Health care assistants
Pharmacists
Therapists
Social workers
Clinical manager
Quality manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Patient(s)
Relative(s)
Point of time in which service user or their reprasentatives' involvement takes place
During the application of the Patient Safety Practice
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
No
Short description of the service users' level of involvement
Not known
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
http://buonepratiche.agenas.it/questionnaire.aspx?id=4833
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
Yes
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Other
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Pasquale Pellino
Country: ITALY
Organisation: FONDAZIONE I.R.C.C.S. POLICLINICO S. MATTEO - PAVIA
E-mail: direzione.sanitaria@smatteo.pv.it
Phone: There is no specified text here
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